"Medication Administration Record (MAR) (For Medications Given Routinely or for a Limited Time)" - Delaware

Medication Administration Record (MAR) (For Medications Given Routinely or for a Limited Time) is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

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MEDICATION ADMINISTRATION RECORD (MAR)
(FOR MEDICATIONS GIVEN ROUTINELY OR FOR A LIMITED TIME)
CHILD’S NAME:
DOB:
ALLERGIES:
PARENT’S/GUARDIAN’S NAME:
DOCTOR:
TELEPHONE:
MONTH AND YEAR:
MEDICATION
1
2
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10
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TIME
INFO
MEDICATION
NAME:
DOSAGE:
ROUTE:
REASON:
START DATE:
END DATE:
SPECIAL INSTRUCTIONS:
I, _____________________________________________, the parent/guardian of the above listed child, give permission for the above medication to be administered.
____________________________________________
________________________________________
Signature
Date
DATE AND TIME
PARENT/GUARDIAN
DATE:
TIME:
COMMENTS/MEDICATION ERRORS/ADVERSE EFFECTS:
INFORMED OF ERRORS
OR ADVERSE EFFECTS
NAME OF PERSON ADMINISTERING
INITIALS
ROUTE OF ADMINISTRATION; SELECT ONE
ORAL (BY MOUTH)
EYE DROPS (OPTIC)
NOSE DROPS/SPRAY (NASAL)
EAR DROPS (OTIC)
TOPICAL (ON SKIN)
INHALATION (NEBULIZER)
INJECTON (SYRINGE, PEN, OR ELECTRONIC INFUSION DEVICE )
RECTAL
MEDICATION ADMINISTRATION RECORD (MAR)
(FOR MEDICATIONS GIVEN ROUTINELY OR FOR A LIMITED TIME)
CHILD’S NAME:
DOB:
ALLERGIES:
PARENT’S/GUARDIAN’S NAME:
DOCTOR:
TELEPHONE:
MONTH AND YEAR:
MEDICATION
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TIME
INFO
MEDICATION
NAME:
DOSAGE:
ROUTE:
REASON:
START DATE:
END DATE:
SPECIAL INSTRUCTIONS:
I, _____________________________________________, the parent/guardian of the above listed child, give permission for the above medication to be administered.
____________________________________________
________________________________________
Signature
Date
DATE AND TIME
PARENT/GUARDIAN
DATE:
TIME:
COMMENTS/MEDICATION ERRORS/ADVERSE EFFECTS:
INFORMED OF ERRORS
OR ADVERSE EFFECTS
NAME OF PERSON ADMINISTERING
INITIALS
ROUTE OF ADMINISTRATION; SELECT ONE
ORAL (BY MOUTH)
EYE DROPS (OPTIC)
NOSE DROPS/SPRAY (NASAL)
EAR DROPS (OTIC)
TOPICAL (ON SKIN)
INHALATION (NEBULIZER)
INJECTON (SYRINGE, PEN, OR ELECTRONIC INFUSION DEVICE )
RECTAL
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